Protocolling

ER Radiology strives to provide rapid and accurate diagnostic services that are in keeping with the best interests of the patients, ER workflow, and society. Our foremost concern is to perform the most appropriate study on each and every patient, and to correctly interpret the study results. For both of these steps, having an appropriate history is essential.

Even for something as simple as a chest x-ray, the clinical history is of great value. Knowing if the chest x-ray is being performed for trauma, or for chest pain, or for shortness of breath greatly assists the radiologist. For instance, a widened mediastinum is a non-specific, but very important finding of traumatic aortic injury. The radiologist’s threshold for considering a mediastinum as wide will be greatly affected by whether the study is of a patient with a history of trauma or chest pain, versus a history of shortness of breath or fever.

For cross-sectional studies, having a history is also essential for ensuring that the right modality is selected and that contrast use is appropriate.

Finally, reimbursement is frequently denied by insurance companies for missing or incomplete histories.

Considering that history is essential for both ensuring performance of the proper study and for interpreting the study performed, nearly every cross-sectional study requires verbal “protocolling.” The following studies do not need to be protocolled (Radiology welcomes the opportunity to discuss imaging options even if a protocol is not needed):

1. Plain films
2. CT brain without contrast
3. CT brain and C-spine for all patients 55 and older with a history of trauma or suspected trauma
4. Ultrasound studies

Protocolling a study involves calling ER Radiology (or the appropriate sub-specialty service) and discussing the case. During evenings (5pm to 11pm) and weekends (11am to 11pm) a Triage Assistant manages all ER Radiology incoming phone calls. The Triage Assistant will collect the relevant history to protocol the study and then will discuss the case with one of the radiologists; the radiologist will either protocol the study, or call the study requester back for further information or to suggest alternative management plans. Please be advised that the primary goal of the radiologist is to ensure that the ordered study is in the patient’s best interests and is an appropriate use of societal resources. Study selection frequently is altered based on these protocolling conversations, and so is an indispensible step in ensuring performance of the best study for each and every patient. Unfortunately, though, protocolling is also one of the largest causes of conflict between Radiology and referring services.

There are several reasons why protocolling results in Emergency Medicine-Radiology conflicts:

1. protocolling takes time for the ordering physician,
2. Radiology phones can be busy and the physician needs to call back,
3. An adversarial atmosphere is created when Radiology suggests an alternative course of action (especially if the recommendation is to forgo imaging altogether), and
4. Radiology might not protocol a study right away, which results in delays of patient care.

Radiology understands these concerns and tries to minimize these frustrations. The onus of ensuring a positive work environment rests with both Radiology and the ordering physicians. There are a couple simple things that ordering physicians can do to help minimize these areas of frustration.

First, order a study before calling to protocol it; the protocolling software does not allow Radiology to protocol a study without it first being ordered. When the radiologist cannot protocol a study at the time of the phone conversation, sometimes the radiologist forgets to come back and protocol it later. Of course, Radiology welcomes discussions about study selection before ordering the study, but then a reminder phone call after the study is placed will prevent this problem of the radiologist forgetting to protocol the previously discussed study.

Second, have all of the relevant clinical information before calling (e.g. creatinine, history of IV contrast allergy, and urine pregnancy test results).

Third, always consider going to the ER Radiology reading room and talking with Radiology directly; face-to-face discussions tend to be much more amicable and frequently resolve issues much faster than if the same discussions are played out on the phone.

Finally, do not hesitate to ask your attending to speak directly with the ER Radiology attending (there is a direct phone line for these purposes). Dr. Howard Forman can be reached at howard.forman@yale.edu to report any concerns about the clinical ER Radiology service.